THE FATE OF THE FORESKIN

A STUDY OF CIRCUMCISION

It is a curious fact that one of the
operations most commonly performed in this country is also
accorded the least critical consideration. In order to decide
whether a child's foreskin should be ablated the normal
anatomy and function of the structure at different ages
should be understood; the danger of conserving the foreskin
must then be weighed against the hazards of the operation,
the mortality and after-effects of which must be known.
Though tens of thousands of infants are circumcised each year
in this country, nowhere are these essential data assembled.
The intention of this paper is to marshal the facts required
by those concerned with deciding the fate of the child's
foreskin.

Origins of Circumcision

Male circumcision, often associated with
analogous sexual mutilations of the female such as clitoric
circumcision and infibulation, is practised over a wide area
of the world by some one-sixth of its population. Over the
Near East, patchily throughout tribal Africa, amongst the
Moslem peoples of India and of South-East Asia, and amongst
the Australasian aborigines circumcision has been regularly
practised for as long as we can tell. Many of the natives
that Columbus found inhabiting the American continent were
circumcised. The earliest Egyptian mummies (2300 B.C.) were
circumcised, and wall paintings to be seen in Egypt show that
it was customary several thousand years earlier still.

According to Elliot Smith circumcision is
one of the characteristic features of a "heliolithic" culture
which, some 15,000 years ago, spread out over much of the
world; others believe that the practice must have arisen
independently among different peoples. In spite of the
enormous literature on the subject (well summarized in
Hasting's Encyclopaedia of Religion and Ethics), we
remain profoundly ignorant of the origins and significance of
this presumably sacrificial rite. The age at which boys are
circumcised varies widely in different races, from the Mosaic
practice of circumcising at about the eighth day, to the
custom in many African tribes of making circumcision part of
an initiation ceremony near the age of puberty. Circumcision
was introduced into Roman Europe with Christianity; little is
known about its status in mediaeval Europe, but it was
probably customary only amongst adherents of the Jewish faith
until, with the rise of modern surgery in the nineteenth
century, its status changed from a religious rite to that of
a common surgical procedure.

Development of the Prepuce

The prepuce appears in the foetus at eight
weeks as a ring of thickened epidermis (Fig. 1, a) which
grows forwards over the base of the glans penis (Fig. 1, b).
It grows more rapidly on the upper surface than the lower,
and so leaves the inferior aspect of the preputial ring
deficient (Hunter, 1935). At 12 weeks the urethra still opens
on the inferior aspect of the shaft of the penis and the
terminal part of the urethra has yet to be constructed.
Arrest at this stage produces the glandular type of
hypospadias, with the ``hooded'' prepuce only partially
covering the glans.

From the inferior aspect of the glans a pair
of outgrowths are pushed out and meet (the sulcus on the
under aspect of the glans marks their fusion), so enclosing a
tube which, becoming continuous with the existing urethra,
advances the meatus to its final site. These outgrowths from
the glans carry with them the prepuce on each side (Fig. 1,
c), thus completing the prepuce inferiorly and forming the
frenulum.

By 16 weeks the prepuce has grown forwards
to the tip of the glans. At this stage (Fig. 1, d) the
epidermis of the deep surface of the prepuce is continuous
with the epidermis covering the glans, both consisting of
squamous epithelium. By a process of desquamation the
preputial space is now formed in the following manner (Deibert, 1933). In
places the squamous cells arrange themselves in whorls,
forming epithelial cell nests. The centres of these
degenerate, so forming a series of spaces (Fig. 1, e); these,
as they increase in size, link up until finally a continuous
preputial space is formed. The stage of development which has
been reached by the time the child is born varies greatly.
Figs. 2, 3, and 4 show sections of the penis in three
full-term newborn infants; in Fig. 2 separation of the
prepuce has not yet begun; in Fig. 3 separation is partial;
in Fig. 4 separation is complete, though this, as will be
shown, is uncommon at birth.

Fig. 2. - Separation of prepuce has not begun and there is
as yet no preputial space.

Fig. 3. - Foci of desquamation leading to partial
separation of prepuce.

Fig. 4. - Separation of prepuce completed to form fully
developed preputial space.

Anatomy of the Prepuce

[CIRP Note: Caution:
Later studies have shown that Dr Gairdner's figures for
increasing retractability after birth are not correct. See Normal Development of the Prepuce
for more information.]

The Younger Child.-The prepuce is
still in the course of developing at the time of birth, and
the fact that its separation is usually still incomplete
renders the normal prepuce of the newborn non-retractable.
(It will be seen that preputial "adhesions" is an inapposite
term to apply to the incompletely separated prepuce,
suggesting as it does that the prepuce and glans were
formerly separate structures.) The age at which complete
separation of the prepuce with full retractability
spontaneously occurs is shown in Fig. 5, which has been
constructed from observations of the prepuce in a series of
100 newborns and about 200 boys of varying ages up to 5
years. Of the newborns, 4% had a fully retractable prepuce,
in 54% the glans could be uncovered enough to reveal the
external meatus, and in the remaining 42% even the tip of the
glans could not be uncovered. Of the older group 10% had been
circumcised and a few had at some time had their prepuce
"stretched"; the figures from which the diagram is
constructed are therefore not precise, but they indicate with
sufficient accuracy that the prepuce is
non-retractable in four out of five normal males of 6
months and in half of normal males of 1 year. By 2 years
about 20% and by 3 years about 10% of boys still have a
non-retractable prepuce.

Fig. 5. - Proportion of boys of varying ages from birth to 5
years, in whom the prepuce has spontaneously become
retractable. Note that it is uncommon for this to occur in
the first six months.

The fact that at these ages
non-retractability depends upon incomplete separation of the
prepuce can be easily demonstrated by running a probe round
the preputial space, gently completing its continuity. It
will then be found that, although the prepuce is often
somewhat tighter than in the adult, it is not tight enough to
prevent retraction. This test was applied to a series of 54
boys aged from 2 months to 3 years who had been referred to
hospital for circumcision, generally with a diagnosis of
phimosis. In 53 of the 54 the prepuce became easily
retractable by this simple manipulation; in one 5-months-old
infant this manoeuvre failed because preputial separation had
not advanced far enough to enable manipulation to complete
the process. Although in this way the prepuce of nearly every
infant can be rendered retractable, the procedure,
necessarily involving the tearing apart of two as yet
incompletely separated surfaces, causes some bleeding and
opens the way to possible infection. For these reasons it is
inadvisable as a routine procedure.

Prepuce of the Older Child. - Of 200
uncircumcised boys aged 5-13 years from three different
schools, 6% had a non-retractable prepuce; in a further 14%
the prepuce could be only partially retracted. In the
majority of boys in this age group non-retractability depends
upon the persistence of a few strands of tissue between
prepuce and glans, so that minimal force is required to
achieve retractability. In this age group, however,
retraction of a hitherto unretracted prepuce discovers
inspissated smegma, which, in contrast to that found in the
younger child, is in some cases malodorous. This, together
with the facts discussed under penile cancer, indicates that
a different view ought to be taken of the non-retractable
prepuce in the child over about 5 years, and that, whereas a
non-retractable prepuce in the young child should be accepted
with equanimity as normal, after about 3 years of age steps
should be taken to render the prepuce of all boys retractable
and capable of being kept clean.

Function of the Prepuce

It is often stated that the prepuce is a
vestigial structure devoid of function. However, it seems to
be no accident that during the years when the child is
incontinent the glans is completely clothed by the prepuce,
for, deprived of this protection, the glans becomes
susceptible to injury from contact with sodden clothes or
napkin. Meatal ulcer is almost confined to circumcised male
infants, and is only occasionally seen in the uncircumcised
child when the prepuce happens to be unusually lax and the
glans consequently exposed (Freud, 1947).

Incidence of Circumcision

Amongst the Western nations the circumcision
of infants is a common practice only with the
English-speaking peoples. It is, for the most part, not the
custom in continental Europe or Scandinavia, or in South
America. In England the collected data of various colleagues*
who have kindly made observations on infants,
school-children, and university students reveal wide
variations as between different districts and between
different social classes. For instance, in
Newcastle-upon-Tyne 12% of 500 male infants aged 12 months
were circumcised; in Cambridge the comparable figure was 31%
of 89 male infants aged 6 to 12 months. Boys coming from the
upper classes are more often circumcised, 67% of 81
13-year-old boys entering a public school had been
circumcised, whereas only 50% of 154 boys aged 5 to 14 in
primary and secondary schools in the rural districts of
Cambridgeshire, and 30% of 141 boys aged 5 to 11 in primary
schools in the town of Cambridge, had been circumcised. The
influence of social class is shown also by some figures
analysed by Sir Alan Rook from a group of university
students. Whereas 84% of 73 students coming from the
best-known public schools had been circumcised, this was so
of only 50% of 174 coming from grammar or secondary schools.
Either the boys of well-to-do parents are suffering
circumcision much too often, or those of poorer parents not
often enough.

In view of the wide difference in the
incidence of circumcised males in different parts of the
country, it is difficult to give an average figure for the
whole country. A conservative estimate of 20%, which is above
the rate for Newcastle-upon-Tyne but well below that for all
the other groups quoted, would mean that the number of
circumcisions performed on children in England and Wales is
of the order of 90,000 annually.

Mortality and Sequelae of Circumcision

Circumcision, like any other operation, is
subject to the risks of haemorrhage and sepsis, and, where a
general anaesthetic is employed, to the risk of anaesthetic
death. The number of deaths presumed to be due to these
causes is shown in the accompanying Table. The
Registrar-General groups circumcision and phimosis together,
but in view of the fact that "phimosis," as the term is
commonly applied to infants, is physiological (see below) it
is probable that the great majority of these deaths were
attributable to operation rather than to any pathological
condition necessitating operation.

Table Showing Deaths in Children Attributed to
Circumcision or Phimosis in England and Wales

Under 1 Year

1-4 Years

Total, Under 5 Years

1942

12

4

16

1943

10

7

17

1944

10

6

16

1945

15

2

17

1946

16

3

19

1947

9

1

10

About 16 deaths in children under 5 years
occur each year from circumcision. In most of the fatalities
which have come to my notice death has occurred for no
apparent reason under anaesthesia, but haemorrhage and
infection have sometimes proved fatal.

Haemorrhage is not uncommon after
circumcision. F. J. W. Miller and S. D. Court (1949, personal
communication), who followed 1,000 infants in
Newcastle-upon-Tyne for their first year, found that 58 were
circumcised, and two of these bled sufficiently to require
blood transfusion. In my own experience about two out of
every 100 children circumcised as hospital out-patients will
be admitted on account of haemorrhage or other untoward
event. Blood losses in the first year are particularly apt to
lead to anaemia, and several infants have been seen with
severe iron-deficiency anaemia following haemorrhages after
circumcision.

Reference has already been made to meatal
ulcer, which, in so far as it is so much more frequent in
circumcised male infants, should be counted a sequel of the
operation.

Pathological Conditions of Prepuce for which
Circumcision is Performed

The surprising variety of reasons why
different doctors advise circumcision and other operations
and manipulations on the prepuce can be found described in
the long correspondence on the subject which ran in the
British Medical Journal from August to November, 1935.
Circumcision is sometimes undertaken in order to cure
existing pathological conditions, sometimes in order to
prevent various diseases from occurring at a much later
date.

Phimosis

Since in the newborn infant the prepuce is
nearly always non-retractable, remaining so generally for
much of the first year at least, and since this normal
non-retractability is not due to tightness of the prepuce
relative to the glans but to incomplete separation of these
two structures, it follows that phimosis (which implies a
pathological constriction of the prepuce) cannot properly be
applied to the infant. Further, the commonly performed
manipulation known as "stretching the foreskin" by forcibly
opening sinus forceps inserted in the preputial orifice
cannot be justified on anatomical grounds, besides being
painful and traumatizing. In spite of the fact that the
preputial orifice often appears minute - the so-called
pin-hole meatus - its effective lumen, when tested by noting
whether or not a good stream of urine is passed, is almost
invariably found to be adequate.

Infants with umbilical or inguinal hernia
are particularly liable to suffer circumcision on account of
``phimosis,'' but if this simple test is applied, rarely will
any obstruction to the urinary flow be found present.
Occasionally the preputial orifice is imperfectly related to
the external meatus, so that the urinary stream balloons out
the subpreputial space; this can be easily remedied by gently
separating the prepuce from the glans in the region of the
meatus by means of a probe. True phimosis causing urinary
obstruction has been described (Campbell, l948), but must be
exceedingly rare: in the cases I have seen in which this
diagnosis has been made, simple separation of the prepuce has
shown that there was no constriction of the preputial
tributable to operation rather than to any pathological
orifice.

Through ignorance of the anatomy of the
prepuce in infancy, mothers and nurses are often instructed
to draw the child's foreskin back regularly, on the
supposition that stretching of the foreskin is what is
required. I have on three occasions seen young boys with a
paraphimosis caused by mothers or nurses who have obediently
carried out such instructions; for, although the size of the
prepuce does allow the glans to be delivered, the fit is
often a close one and slight swelling of the glans, such as
may result from forceful efforts at retraction, may make its
reduction difficult.

Balanitis and Posthitis

Inflammation of the glans is uncommon in
childhood when the prepuce is performing its protective
function. Posthitis - inflammation of the prepuce - is
commoner, and it occurs in two forms. One form is a
cellulitis of the prepuce; this responds well to chemotherapy
and does not seem to have any tendency to recur; hence it is
questionable whether circumcision is indicated. More often
inflammation of the prepuce is part of an ammonia dermatitis
affecting the napkin area. The nature of this condition was
firmly established by Cooke in 1921, bit is still not
universally known. The urea-splitting Bact.
ammoniagenes (derived from faecal flora) acts upon the
urea in the urine and liberates ammonia. This irritates the
skin, which becomes peculiarly thickened, while superficial
desquamation produces a silvery sheen on the skin as if it
were covered with a film of tissue paper. Such appearances
are diagnostic of ammonia dermatitis, and inquiry will
confirm that the napkins, particularly those left on through
the longer night interval, smell powerfully of ammonia.
Treatment consists in impregnating the napkins with a mild
antiseptic inhibiting the growth of the urea-splitting
organisms. For this purpose boric acid powder sprinkled over
the napkins, or a rinse of 1 in 4,000 mercuric chloride or of
the recently introduced non-toxic substance "diaparene"
(Benson et al., 1949), are gratifyingly effective.

When involved in an ammonia dermatitis the
prepuce shows the characteristic thickening of the skin, and
this is often labelled a "redundant prepuce" - another
misnomer which may serve as a reason for circumcision. The
importance of recognizing ammonia dermatitis lies in the
danger that if circumcision is performed the delicate glans,
deprived of its proper protection, is particularly apt to
share in the inflammation and to develop a meatal ulcer. Once
formed, a meatal ulcer is often most difficult to cure.

Enuresis

A number of symptoms of obscure cause,
such as enuresis, masturbation, habit spasm, night terrors,
or even convulsions, have from time to time been attributed
to phimosis, and circumcision has been advised. No evidence
exists that a prepuce whose only fault is that it has not yet
developed retractability can cause such symptoms.

It may be apposite at this stage to quote
the reasons given by the mother for desiring her child's
circumcision in a series of 54 infants referred to hospital
by a doctor. In 39 infants the reason was a symptomless
``phimosis'' found on routine inspection by doctor, nurse,
mother, or neighbour. In nine cases it was said that ``he
cries when he wets'': five of these proved to be due to
ammonia dermatitis; closer questioning of the others revealed
either no connexion between when the baby cried and when he
urinated, or merely that crying often started micturition. In
these three cases the foreskin was judged to be too long or
redundant, and in a further three the reason was even more
frankly cosmetic ("it looks funny") or was intangible ("we
believe in it"). As has been stated earlier, in all except
one of this group of 54 infants, phimosis was disproved, in
so far as gentle manipulation enabled the prepuce to be
retracted.

Conditions Prevented by Circumcision

Universal circumcision of male infants has
been urged as a means of preventing the later development of
a variety of conditions - paraphimosis, venereal diseases,
penile cancer, and cervical cancer of women.

Paraphimosis

Some idea of the importance of
paraphimosis can be gained from figures from the Royal
Victoria Infirmary, Newcastle-upon-Tyne, a hospital serving a
large population in which, as has been mentioned, infants are
circumcised less often than in the country generally. In the
children's wards paraphimosis accounts for about seven out of
a total of 800 male child admissions each year (0.9%); an
appreciable number of these are found to be the result of the
mother's obeying misguided instructions to retract her
infant's prepuce forcibly. In the adult wards it accounts for
about 10 out of a total of 5,000 male surgical admissions
(0.1%), so that paraphimosis scarcely constitutes an
important hazard to the uncircumcised male.

Venereal Disease

Although there is a common belief that the
circumcised man runs a lessened risk of venereal infection,
particularly syphilitic, there are few figures to support
this. Lloyd and Lloyd (1934), who reviewed the published
evidence and analysed their own figures, concluded that
circumcision did not diminish the chance of a syphilitic
chancre. Schrek and Lenowitz (1947) found that hospital
patients gave a history of venereal disease equally often
whether circumcised or not. Wilson (1947) has published
figures showing that, of the men attending a Canadian Army
venereal disease centre, the proportion of uncircumcised
solders (77%) was higher than in the Canadian Army generally
(52%), and concluded that the uncircumcised soldier is more
prone to venereal infection. It may be, however, that since
circumcision of infants is de rigueur in Canada, the
uncircumcised man will tend to come from a lower social grade
and thus to be more likely to expose himself to infection.
The evidence seems scarcely to warrant universal circumcision
as a prophylactic against venereal infection.

Penile Cancer

This subject merits careful appraisal, for
it alone, of the medical reasons commonly advanced for the
universal circumcision of infants is capable of withstanding
critical scrutiny. In England and Wales deaths from penile
cancer number about 150 a year. The relation between this
disease and antecedent circumcision has recently been
reviewed by Kennaway (1947). All observers agree that
circumcision in the first five years of life protects
absolutely from penile cancer, and this applies not only to
one group such as the Jewish but equally to the mixed races
of the U.S.A. The reason for this preventive effect of early
circumcision is not known: it is not due to removal of the
cancer-bearing area since the usual site of penile cancer,
the sulcus behind the glans, is retained. If it is due to
retained smegma or its decomposition products being
carcinogenic, this effect must be of startling potency, since
circumcision after the fifth year fails to prevent cancer
occurring several decades later.

A clue to the problem may lie in the
exceptionally low hygienic standards of patients with penile
cancer, which has struck several observers. Dean (1935),
reviewing 120 cases, writes: "Men with penis cancers gave the
impression of being less intelligent, as a class, than other
cancer patients. Not only had the majority ignored for long
periods the precancerous state of physical annoyance, filth,
and odoriferous discharges, but also it was not unusual for
many to delay seeking advice until a large part of the penis
bad become affected with an ulcerating growth." The unusual
frequency with which patients with penile cancer have had
venereal disease has been demonstrated by Dean (1935) and by
Schrek and Lenowitz (1947), these authors having come to the
conclusion that this fact indicates again the significantly
low standard of social hygiene of these patients. A further
factor frequently present in patients with penile cancer is
phimosis; although this is often the result of the growth, in
many patients the prepuce has never been retractable (Lewis,
1931).

With these facts it may reasonably be
contended that, if the uncircumcised male has a prepuce which
he can retract and which he keeps clean, he is likely to
enjoy the same immunity from penile cancer as his circumcised
brother.

Cervical Cancer In Women

The low incidence of cervical cancer among
Jewesses has led Handley (1947) to the conclusion that this
disease is mainly caused by the introduction of irritant
material by the uncircumcised husband during coitus. It
should be a simple matter to put this theory to the test by
noting whether the husbands of women with cervical cancer are
more frequently uncircumcised than others. Meanwhile the
evidence seems insufficient to warrant universal circumcision
or preputiotomy, such as Handley advocates.

Minor Advantages of Circumcision

There remain a number of more or less
trivial factors which are sometimes mentioned as reasons why
infant circumcision is desirable: difficulties in keeping the
uncircumcised parts clean, or the supposed aesthetic or
erotic superiority of the shorn member. In order to fulfil
the intention of this paper an inquiry on these points should
have been made amongst a group of uncircumcised men. This was
not attempted, although with regard to the last two of the
factors mentioned it should be stated that whenever the
subject has been broached in male company those still in
possession of their foreskin have been forward in their
insistence that any differences which may exist in such
matters operate emphatically to their own advantage.

Moreover, if there were sensible
disadvantages in being uncircumcised, one would expect that
the fathers of candidates for circumcision would sometimes
register their feelings in the matter. Yet in interviewing
the parents of several hundred infants referred for
circumcision I have met but one father who wished his son
circumcised because of his disagreeable experience of the
uncircumcised state. The rest of the fathers were equally
indifferent about the matter whether they themselves had been
circumcised or not. Indeed, so little did the father's
personal experience seem important that one-quarter of the
mothers did not even know whether their husbands were or were
not circumcised. These facts provide some evidence that few
uncircumcised men have cause to regret their state.

Conclusions

It has been shown that, since during the
first few year of life the prepuce is still in process of
developing, it is impossible at this period to determine in
which infants the prepuce will attain normal retractability.
In fact, only about 10% will fail to attain this by the age
of 3 years. Of this 10% of 3-year-old boys, in most it will
be found a simple matter to render the prepuce retractable by
completing its separation from the glans by gentle
manipulation. In a very few this may prove impossible and
circumcision might then be considered a justifiable
precaution.* * Higgins (1949), with long experience of
paediatric urology, also concludes that circumcision should
not be considered until "after the age of, say, 2 to 3
years."

The prepuce of the
young infant should therefore be left in its natural
state. As soon as it becomes retractable, which will
generally occur some time between 9 months and 3 years, its
toilet should be included in the routine of bath time, and
soap and water applied to it in the same fashion as to other
structures, such as the ears, which are customarily treated
with special assiduousness on account of their propensity to
retain dirt. As the boy grows up he should be taught to keep
his prepuce clean himself, just as he is taught to wash his
ears. If such a procedure became customary the circumcision
of children would become an uncommon operation. This would
result in the saving of about 16 children's lives lost from
circumcision each year in this country, besides saving much
parental anxiety and an appreciable amount of the time of
doctors and nurses.

Summary

The development of the prepuce is
incomplete in the newborn male child, and separation from the
glans, rendering it retractable, does not usually occur until
some time between 9 months and 3 years. True phimosis is
extremely rare in infancy.

During the first year or two of life, when
the infant is incontinent, the prepuce fulfils an essential
function in protecting the glans. Its removal predisposes to
meatal ulceration.

The many and varied reasons commonly
advanced for circumcising infants are critically examined.
None are convincing.

Though early circumcision will prevent
penile cancer, there is reason to suppose that keeping the
prepuce clean would have a like effect in preventing this
disease.

In the light of these facts a conservative
attitude towards the prepuce is proposed, and a routine for
its hygiene is suggested. If adopted this would eliminate the
vast majority of the tens of thousands of circumcision
operations performed annually in this country, along with
their yearly toll of some 16 child deaths.